Philosophical Fluoro Question and Rant


St. Joseph County, Indiana
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Philosophical question: Are they going to eventually bundle fluoro with all pain procedures eventually?

Rant: I completely disagree with the AMA's bundling of fluoro primarily due to the personal risk associated with fluoro. Pain fluoro is the only radiological service where the physician stands next to the x-ray device. While the physician is shielded with aprons, collars, glasses and even lead-lined latex gloves, the phsyician is still exposed radiation several thousand times a year. Also the physician is personally manipulating and directing the equipment...Not sitting in a dark room hundreds of miles away reviewing films.

Thank you and good night

Brock Berta


Denver Colorado
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We need to consider another reason that the AMA included the requirement of image guidance with both the facet joint injection and transforaminal epidural injection codes...

The utilization / frequency of both of these codes sets have ESCALATED in recent years. Both of these procedures have been on the OIG Work Plans in the last few years with corresponding reports that showed abysmal error findings. There have been many claims reviewed that these procedures were being performed WITHOUT any image guidance, mostly by providers who were trained in a weekend course and don't have / can't get access to either fluoroscopy or CT for image guidance and localization. Often this technique is referred to as "blind" or anatomically guided. Typically the providers performing these procedures without image guidance are not pain management specialty providers but they get paid just the same as those providers that do verify their needle placements. In many cases, during the rewiews, these procedures were determined to more likely be either trigger point injections or other peripheral nerve injections at best, but again the providers that were not using image guidance got paid just the same as our pain mangement providers.

One mechanism to require the use of image guidance for these procedures was to change / revise the code descriptors, in that if the injection procedure was performed without image guidance, it would not be compliant to report these codes. Payer review could consider it to be fraudulent billing if a provider billed these new / revised codes when they were performing these procedures via a "blind" / anatomic guidance technique.

The change in RVU for these codes was in part based on the information obtained from practice surveys regarding physician work and practice expense currently associated with these procedures.

I agree with your sentiments regarding the changes but we also need to hold those practices accountable that are driven purely by revenue and report procedures non-compliantly.